Lessons in negligence prevention

Lessons in negligence prevention – running a hospital and failed risk management

Nine babies might have been saved or escaped harm had hospital managers and doctors not missed vital opportunities to stop Lucy Letby’s killing spree.

On up to ten occasions, suspicions were raised or events happened that linked her to the spike in deaths or collapses at the Countess of Chester Hospital’s neonatal unit.

Crucially, doctors failed to appreciate the significance of blood test results from two baby boys – treated eight months apart – which proved that someone on the ward was poisoning children with insulin.

When consultants finally became suspicious and demanded Letby be removed from her frontline job, hospital bosses refused to believe she was to blame.

Desperate to protect the reputation of the trust, bosses moved her into an office job. But they fought to get her reinstated onto the neo-natal unit – even insisting senior medics write her a letter of apology when a formal employment grievance she pursued apparently found little evidence she had done anything wrong.

In the end, consultants were so terrified about having her anywhere near their patients that they demanded CCTV be installed on the unit. They eventually persuaded executives to go to the police in May 2017 and blocked her return.

Dr Stephen Brearey, the consultant paediatrician in charge of the unit, accused hospital management of a ‘cover-up’.

His colleague, TV medic Dr Ravi Jayaram, said lives could have been saved had managers acted on their concerns sooner and accused them of failing to act to protect the hospital’s reputation.

Dr John Gibbs, another consultant paediatrician at the hospital, said: ‘In the 11 months before the police got involved after we raised concerns, senior managers were extremely reluctant to involve the police, to discuss what was happening. We had to keep insisting the police be involved.’

Missed chance 1

The trial was told that the link between Letby and the unexpected collapses and deaths was first made as early as June 2015 when three babies died and another had to be resuscitated within the space of a fortnight. Dr Brearey was so worried he decided to carry out an informal review into the deaths of the infants, known as Babies A, C and D, and the unexpected collapse of Baby A’s twin sister.

Despite this, and notifying the directors, no steps are taken.

Missed chance 2

One of the consultants, who was not named in court for legal reasons, realised the results were abnormal. She even looked to see if any other babies on the unit were being given insulin at the same time – which they weren’t.

But she did not suspect foul play. She failed to flag the results to Dr Brearey or any other colleagues and they were effectively ignored.

Missed chance 3

Almost three more months passed, during which time Letby attacked another baby girl before she murdered her fifth patient. The infant, another premature baby girl, known as Baby I, died on October 23. Later that day consultants on the neo-natal unit decided to flag their concerns again in an email to Mrs Kelly.

However, Dr Jayaram said they were ‘fobbed off’ and Letby was allowed to continue working.

Missed chance 4

Soon afterwards, Dr Brearey commissioned an independent neonatologist to carry out a ‘thematic review’ of deaths on the unit. Dr Nim Subhedar, who was based at the Liverpool Women’s Hospital, reported his findings on February 8, 2016.

Although Dr Subhedar found no explanation for the increase in deaths, Dr Subhedar also flagged that Letby was the only nurse on duty during each event. He had been unaware that the association had been made previously, Dr Brearey said.

Missed chance 5

In the same month, Dr Jayaram’s suspicions heightened when he believed he interrupted Letby tampering with the breathing tube of a very premature baby girl, known as Baby K.

He claimed he found Letby stood next to the baby’s incubator ‘doing nothing’ even though her oxygen levels were dropping and she had begun to collapse. Baby K was transferred to Arrowe Park, where she died three days later. Letby was charged with attempted murder of Baby K but the jury failed to reach a verdict in her case.

Dr Jayaram admitted he failed to confront Letby, make a note of his suspicions in Baby K’s medical notes, or put in a formal report or complaint. He explained medics ‘were thinking the unthinkable’ and insisted hospital management was aware of his and his colleagues’ concerns. But another chance was lost.

Missed chance 6

Around this time, Dr Brearey demanded an urgent meeting with the hospital’s executive team.

However, his request was ignored for another three months and Dr Jayaram said medics ‘faced pressure… not to make a fuss.’ Dr Jayaram said: ‘I wish we had bypassed [the managers] and gone straight to the police. We by no means were playing judge and jury at any point but the association [with Letby] was becoming clearer and clearer.’

Missed chance 7

In February 2016 the hospital was inspected by the independent health watchdog, the Care Quality Commission.

Sources told the Health Service Journal that concerns were raised about the high mortality rate on the unit, and the difficulties faced by consultants in getting managers to take their concerns seriously.

Although the CQC report raised issues around staffing levels and the skill mix on the neo-natal unit, both children’s and maternity services overall were rated ‘good.’

Our dispute resolution team deal with all aspects of negligence. Contact Bond Adams Solicitors on 01162858080 or lawyers@bondadams.com.

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